KAMALIKA PIERIS
Surgical specialties were introduced to the state health sector in the late 1950s. The General Hospital Colombo was the first to get permanent special units, such as a thoracic unit, observed History of Surgery. But some specialties were started in the provincial hospitals as well. Doctors who had trained in specialized surgery abroad introduced these specialties to the provincial hospitals they were sent to.
A cancer unit was started in Maharagama in 1958, thoracic unit in Ratnapura in 1958, plastic surgery unit in Kurunegala in 1971, Urology at Nawalapitiya in 1974 and gastro intestinal surgery at Base Hospital, Kuliyapitiya. General hospital, Kandy had an orthopedic unit in 1961, urology in 1968, neuro-surgery in 1972 and vascular surgery in 1974.
Specialist surgeons did not find it easy to establish their specialties in a hospital. The Ministry of Health sent them for training, appointed them as specialists on their return, got them the surgical instruments they asked for and then forget about them. The rest was up to the personal initiative of the surgeon. Urology is a good example.
Urology was established as a specialty in Sri Lanka in 1954 in the General Hospital, Colombo. Dr GN Perera was the sole urologist for the whole country at that time. He had just 10 beds, no house officers and had to share operating time with others. He faced resistance from the general surgeons at the beginning. Some even sought legal action against him for using general surgery procedures in his work.
Dr. Lakshman Attygalle who was appointed as urologist in Colombo in 1971 was also the sole urologist until he was joined by Dr Lalith Perera. Attygalle worked with only XRays to guide him, said the History of Surgery and his operation list sometimes had 30 patients. He had worked 3 operating tables at the same time.
Dr. AML Beligaswatte related the trials and tribulations he had to undergo to develop the urology unit in Kandy. The urology unit in Kandy was without a doctor till Beligaswatte returned in 1978. As usual, he was appointed without the infrastructure and facilities he needed, including supporting staff. He had to start from scratch.
Dr. Beligaswatte arranged with a colleague to share his clinic room in the OPD to set up a urology clinic but he had no operating theater facilities. A VVIP with a urological condition had been sent to him one day, and Dr.Beligaswatte had explained that he could not carry out the necessary surgery as he did not have the facilities. Within two months he had all the equipment he needed. Dr Beligaswatte found an empty ward occupied by bats. The Matron, male nurse and the administration officer had urged the Medical Superintendant of the hospital to release the ward for urology. Dr Mark Amerasinghe the Orthopedic surgeon gave him an afternoon session in the operating theatre.
Until the PGIM came on the scene, there were only these three urological surgeons in the country, the two in Colombo and the one in Kandy and patients came from all over the island to these units.
Then In 1980, PGIM started to train urologists. Over 25 Urologists went on to open up urology units throughout the country. Urology gained strength as a specialty and Sri Lanka Association of Urological surgeons was set up in 1999. It received the membership of Urological Association of Asia in 2003.
But the surgeons continued to face the same difficulties and found solutions on their own. In Kurunegala the urologist only had a single afternoon operating session a week but with the support of the anesthetist and nurses, he operated from 2 pm to 7 pm. The nursing staff were sent to Kandy for training in urology. The Inner Wheel club had helped to develop the urology ward and clinic in Kurunegala.
At Karapitiya, Dr Himashi Kularatne was appointed Neuro surgeon in 1997. He had no beds, instruments or theatre facilities. An American ship en route via Sri Lanka to US after the Gulf War in 1991 had donated some hospital beds and other equipment. These had been dumped in stores and Himashi was able to find ‘some beds, mattresses, blood pressure apparatus, ophthalmoscope and some minor surgical instruments from this collection’.
The Ministry said it had no funds to develop the unit, but the Minister and the Director General of Health had helped to get the rest of the equipment needed. Karapitiya finally had a well equipped neurosurgery unit along with an intensive care unit and a new theatre. Himashi said he was the only neurosurgeon in the hospital and he had to work day and night through the year” to treat patients. All patients with head injury due to the Tsunami were treated in his unit, he recalled with much satisfaction.
Young trainees are now returning with skills and the equipment to handle complex surgical problems observed History of Surgery. the fibreoptic gastro duodenoscope, an instrument used to look into the duodenum, was introduced to Sri Lanka by DFDS Goonewardene who had trained in its use in Japan.
Dr K.L. Fernando performed the first laparoscopic removal of the gall bladder, at Ragama using equipment purchased by him in Germany when training there. When I planned to return to Sri Lanka in 1992, I managed to buy most of the necessary equipment. A German surgeon helped me to buy hand instruments at a relatively cheap price. I hand carried them back, he said.
For the first operation everything was planned well ahead. Certain instruments I fabricated myself by altering old instruments. Crocodile forceps were fabricated by me. I could not bring back carbon dioxide insufflators which were costly. I used the old hand operated ones which were available in Gynecology. I had brought two empty gas cylinders from UK which I used for this procedure and during the initial period I had to go to Ceylon Oxygen Company to fill them as the hospital did not have carbon dioxide.”
I made two big trays with aluminum sheet to sterilize the instruments, continued Fernando. The video camera was inserted into a sterilized sheath made out of cloth by the operating theater sister. I trained a few experienced theatre nurses in what to expect and a final year medical student was taught how to hold the telescope during the procedure. The instruments were brought to hospital in my car and final year medical students helped to carry them to the operation theatre. After the first successful operation, Dr Fernando went on to train surgeons in both state and private sector in this procedure.
Dr Waruna Karunaratne, thoracic surgeon, trained in Germany. On his return, in 2004, he was appointed to Welisara where he set up a thoracic unit. His German contacts sent him equipment and also visited him to advice on the unit. Some of the equipment they sent was not allowed in by Sri Lanka Customs even after they were shown documents.
Similarly, Klinik Lowenstein had sent 80 electrically controlled beds free of charge to replace the beds at Welisara, but the Ministry had refused to pay the freight charges which were 1.2 million rupees and the beds went back. Each bed was worth two million and the beds were up to date, said Waruna. It took a long time to persuade the Ministry to buy the thorascopic instruments needed for Welisara, and Waruna was able to perform the first thorascopic surgery only in 2007.
One of the earliest surgical specialties available in Sri Lanka was heart surgery. A T S Paul was sent for special training in thoracic surgery in UK. On his return he established a thoracic surgery unit at the General Hospital, Colombo in 1952, the first such unit in Sri Lanka. For many years this was the only cardiothoracic unit in the island. Dr Paul also later designed a portable heart-lung machine and kidney dialysis machine
The first closed heart surgery operations were done in 1953 in Colombo by Prof Ric Husfeld, Professor of thoracic surgery in Copenhagen, Denmark, who was visiting Sri Lanka as part of a medical team sponsored by WHO. Open heart surgery followed thereafter, in the 1950s. it was reported that between 1954 and 1975 625 cases of hole in the heart, were corrected. In 1968, the first intensive care unit in Ceylon was established by anesthetist Dr Thistle Jayawardene for taking care of these cardiac surgical patients.
In 1961 Britain had offered Sri Lanka a heart-lung machine, but had decided to send a team to Sri Lanka first.The team had reported that there was friction between the two cardiac units in Colombo and suggested that the machine be offered to Singapore. The first heart lung machine came in 1966, donated by Lions Club. But this was not what the local surgeons wanted, so a machine was designed and built locally.
Heart surgery in Sri Lanka has received much praise. In 2008 US Cardiac Surgeon Dr J.R.Torstveit stated in an interview with the Daily News that Sri Lanka was on par with the best when it came to open heart surgery on children. The success rate at Lady Ridgway Hospital had gone beyond 95 % which places it on par with the very best in countries like US and UK. This was attributed to the selfless dedication and commitment by both local doctors and authorities.
In 2014 Consultant Cardiothoracic Surgeon Dr. Mahendra Munasinghe told Sunday Times, that Heart surgery in Sri Lanka has developed in leaps and bounds and now we are on par with any country, the country has the expertise and the technology to bring about satisfactory results in a variety of cases. He said that heart surgery has reached a high standard in the five Government cardiac- surgical units at the National Hospital in Colombo, the Kandy and Karapitiya Teaching Hospitals, the Lady Ridgeway Hospital for Children in Colombo and the Sri Jayewardenepura General Hospital.
India did a survey of heart surgery inBangladesh, Bhutan, Nepal, Maldives, Pakistan and Sri Lanka and this was reported in Indian Heart Journal in 2017. It said that the approximate number of cardiac operations performed in Sri Lanka in 2016 is 5500. The number of operating surgeons is 24. The number of cardiac anesthetists and perfusionists is 21 and 48 respectively. There are 11 centers offering cardiac surgery in Sri Lanka. These centers are located in Colombo, Kandy, Galle and Jaffna. In 2016 the estimated Sri Lankan population is 21 million. That makes the number of cardiac operations around 265/million population, which is by far better than that of any other South Asian nation, including India.
Sri Lanka has developed a capacity for transplant surgery for kidney, liver and heart. This was probably a late development but it is available now, within limits. The start was at National Hospital, Colombo, but later transplant units were set up in Sri Jayewardenepura, Kandy, Peradeniya, Karapitiya and several private hospitals, reported the History of Surgery.
Transplant surgery started due to the dedication of three doctors, H. Sheriffdeen, Rizvi Sherif and Geri Jayasekera. These three have not, in my view, received the recognition due to them for their successful introduction of transplant surgery in Sri Lanka.
In 1978, these three doctors, H. Sheriffdeen, Riziv Sherif and Geri Jayasekera observed that patients were going to India for renal transplants. They discussed the possibility of setting up a renal transplantation programme in Sri Lanka. The aim was to provide a service to patients,but also raise the level of surgical expertise in the country and bring it in line with global standards.
This first venture into transplant surgery was carefully planned over a period of time. Sheriffdeen used his sabbatical leave to undergo training in renal transplantation in the UK and USA. Rizvi Sheriff set up the necessary dialysis unit in 1980-1985, in the private sector at Lanka Medicare hospital first and later in the National Hospital, Colombo. Geri Jayasekera attended to his function in the matter.
Sheriffdeen returned after training in 1981 and preparatory work for kidney transplant started. Several meetings and workshops were conducted to create awareness and train the support staff. A high level team was assembled for the first operation. This consisted not only of the operating theatre team, but also specialists in pathology, hematology, microbiology and physiology. A specialist on dialysis and technicians from a private lab were brought in. Nurses were specially trained. The team also had an adviser on medico- legal issues.
In 1985 the first living donor kidney transplant operation was successfully carried out by this team at Rutnams Private Hospital, Colombo as permission to carry out this operation in the National Hospital was denied.
Two years later, National Hospital (NHSL) had its first kidney transplantation operation, done by the same team. First pediatric transplantation was also done at the NHSL by them in 1987. The NHSL continued to strengthen its transplant programme and in 1997 the first transplant using organs from brain dead person (cadaveric) was carried out there.
There were legal issues involved in transplant surgery. The Sheriffdeen team lobbied the Minster of Health and obtained the Transplantation of Human tissues Act no 48 of 1987. With the development of transplant surgery, there was also the need to find donors, and doctors Island wide were alerted about the need to obtain organs from brain dead persons.
The next hospital to move into renal transplant was predictably Kandy Teaching Hospital. Kandy has had a successful renal transplant programme said History of Surgery. The first live donor kidney transplant was done in Kandy in 2000. As at 2021 1286 live donor kidney transplants and 189 deceased donor kidney transplants have been performed in Kandy. The first 50 cadaveric cases when reviewed were found to be similar to other international series.The first successful heart transplant was in July 2017 at Kandy. The first kidney pancreas transplant was also attempted in 2017 in Kandy.
The first pediatric renal transplant program in the island was developed at Peradeniya Teaching Hospital in 2004. And the first transplant was performed in the same year, said History of Surgery. As at 2021, the hospital had done 134 operations. There is a separate transplant ward in the hospital. Peradeniya teaching Hospital is recognized as the only unit that provides Pediatric kidney transplant service in Sri Lanka.
The Peradeniya surgeons said they developed this capability amidst many obstacles and difficulties, working without the necessary supporting facilities. Patients were underprepared for the operation due to lack of facilities and their nutritional status was low.
The surgical team that pioneered this consisted of Oswald Fernando, MD Lamawansa and Chula Gunasekera. Oswald Fernando was the transplant surgeon at Royal Free Hospital London. He had been instrumental in getting our surgeons to London for training in transplant surgery. Dr Fernando led the Peradeniya pediatric transplant operation. Dr Lamawansa had trained in pediatric transplant at the Royal Free. Dr Chula Gunasekera had seen to the pre-operative aspect. The Medical Faculty at Peradeniya greatly supported this venture. The History of Surgery mentions by name the academics who helped. The Faculty was very proud of its achievement in pediatric transplant surgery.
But not everybody was pleased. The Surgeon in charge of the Kandy adult transplantation programme, used his influence as President of the local branch of the GMOA to persuade Peradeniya authorities and the Ministry to order a halt to the Peradeniya programme, after the first successful transplant operation.
The Minster for Health, Nimal Siripala de Silva arrived to settle the matter. After listening to all parties at a “not so pleasant meeting” he decided to divide the 27 children who were awaiting operations, among the three hospitals Lady Ridgway, Kandy and Peradeniya which claimed that they were capable of doing transplants on children. Each hospital was allocated nine children each. But all 27 operations were performed at Peradeniya since the parents were not prepared to send their children to hospitals they were not familiar with.
Lastly, we come to liver transplants. The University of Colombo Transplantation unit performed the first successful liver transplant at NHSL in 2010. One unique feature in this operation was that the surgical team had managed all aspects of patient care from pre –op to post –op, because there was nobody else who could undertake this.
University of Kelaniya Faculty of Medicine had established a dedicated liver unit which moved on to liver transplants. They did the first successful live donor liver transplant (LDLT) at Nawaloka Hospital in 2013. In 2017, this team also did the first liver transplant for acute liver failure. This was challenging surgery to perform in a starting programme said History of Surgery. In 2020 the team went on to perform 50 liver transplants, the highest in the island. This included the first pediatric liver transplant in the country. The center then went on to train surgeons in liver transplant. (Continued)
